Chapter 13Nutrition for a Life time
Energy Needs During Pregnancy
• 1st trimester
– Balanced and adequate diet
• 2nd and 3rd trimester
– 350-450 extra kcal per day
3rd trimester
Transfer of fat, calcium, and iron to fetus during the last month Fetus may deplete mother’s store of iron if intake is low
• Choose nutrient dense foods
• Physical Activity
– Increase kcalories if exercising
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Folic Acid
Strong evidence that folic acid prevents preconceptionally recurrent and first occurent neural tube defects
Increasing evidence that folic acid reduces risk of some other birth defects
Improves the hematologic indices in women receiving routine iron and folic acid
USPHS/CDC recommends for US women
400 g/day: All women in childbearing age 1 mg/day: Pregnant women 4 mg/day: Women with history of neural tube defect
deliveries take folic acid 1 month prior to conception and during first trimester
Czeizel 1993; Czeizel and Dudas 1992; Mahomed et al 1998; MRC Vitamin Study Research Group 1991.
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Iron Supplementation
Iron requirements:
Average non-pregnant adult:
– 800 g iron lost/day– + 500 g iron lost/day during menses
Pregnant woman: Increased need
– Expanded blood volume– Fetal and placental requirements– Blood loss during delivery
Routine vs. selective iron supplementation:
Prevalence of nutritional anemia Routine iron and folate supplementation where nutritional
anemia is prevalent Recommended dose: 60 mg elemental iron + 5 g folic acid
Mahomed 2000b; WHO 1994.
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Iodine Supplementation
Iodine deficiency is a preventable cause of mental impairment
Iodine supplementation and fortification programs have been largely successful in decreasing iodine deficiency conditions
Population with high levels of mental retardation (e.g., some parts of China):
Supplementation may be effective at preconception up to mid-pregnancy period
Form of iodine supplementation (iodinating food or oral/injectable iodine) depend on:
– Severity of iodine deficiency– Cost– Availability of different preparation
Enkin et al 2000; Mahomed and Gülmezoglu 2000.
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Vitamin A Indications for vitamin A supplementation:
Vertical transmission of HIV (ongoing) Infant survival Maternal anemia: Positive interaction with iron in reducing
anemia Infection Maternal mortality:
– Vitamin A vs. placebo RR 0.60 (0.37–0.97)– Beta-carotene vs. placebo RR 0.51 (0.30–0.86)
Potential adverse effects of Vitamin A and related substances:
Total daily dose > 10,000 IU before 7th week of gestation associated with birth defects: craniofacial, central nervous system, thymic cardiac
Overall effectiveness and safety of vitamin A supplementation needs to be evaluated
Rothman et al 1995; Suharno et al 1993;
West et al 1999.
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Other Micronutrients: Calcium
Association between reduction in pregnancy induced hypertension (PIH) and calcium supplementation
Reduction of incidence of PIH Routine supplementation likely beneficial in women at high risk
of developing PIH or have low dietary calcium intake High calcium doses (2 g/day) not associated with adverse
events Need adequately sized and designed trials in different settings
to confirm beneficial effects Recommend increase in calcium intake through diet in women at
risk of hypertension or low calcium areas
Bucher et al 1996; Kulier et al 1998; Lopez-Jaramillo et al 1997.
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Calcium Supplementation: Conclusions
Calcium decreases risk of hypertension, pre-eclampsia, low birth weight, and chronic hypertension in children
Recommend for high risk women with low calcium intake, if pre-eclampsia is important in the population
Calcium has other health benefits not related to pregnancy:
Maintaining bone strength Proper muscle contraction Blood clotting Cell membrane function Healthy teeth
Atallah, Hofmeyr and Duley 2000.
Recommended weight grain during pregnancy
• 2 - 4 lb. weight gain during 1st trimester
• 0.75 - 1 lb. weekly weight gain during
2nd and 3rd trimester • Total weight gain goal
– 25 - 35 lb. for normal weight women – 28 - 40 lb. for low weight (BMI < 19.8) – 15 - 25 for high weight (BMI 26-29) – 15 - 25 lb. for obese (BMI > 29)
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Components of Weight Gain
10Nutrition and Micronutrients in Pregnancy
Protein and Carbohydrate need during pregnancy
RDA for protein
– Additional 25 gm/day – Many (non-pregnant) women already
consume recommended amount of protein
• RDA for carbohydrate
– Prevent ketosis – 175 gm/day – Most women exceed this amount
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Additional Mineral Need • Calcium (1000 mg/day)
– Adequate mineralization of fetal skeleton and teeth Iron (27 mg/day)
Increased hemoglobin Iron stores for the fetus Iron supplement between meals
• Possible effects of iron-deficiency anemia
– Preterm delivery – Low-birth weight – Fetal deaths
• Zinc (11 mg/day)
supports growth and development
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Pregnant vs. Nonpregnanat
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Energy/Nutrient Non-pregnant Pregnant
Protein 46 g/day 71 g/day
Vitamin C 75 mg/day 85 mg/day
Thiamin 1.1 mg/day 1.4 mg/day
Niacin 14 mg/day 18 mg/day
Folate 400 mcg/day 600 mg/day
Vitamin D 5 mcg/day 5 mcg/day
Calcium 1000 mg/day 1000 mg/day
Iron 18 mg/day 27 mg/day
Iodine 150 mcg/day 220 mcg/day
What about Aspartame Harmful for mothers with phenylketonuria (PKU)
– Disrupts fetal brain development
• Moderate use not harmful for women who do not have PKU
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What about Caffeine Decreases iron absorption
• May reduce blood flow through the placenta
• Caffeine withdrawal symptoms in newborn
• Risk of spontaneous abortion
– Heavy caffeine use in the 1st trimester
• Risk of low-birth-weight infant
• Limit caffeine intake (< 3 cups coffee/day)
Pregnancy Complications
Gestational Diabetes
– Hormones synthesized by placenta decrease action of insulin – 4% of pregnancies; 7% of Caucasian women – Routine screening at 20 - 28 weeks gestation
• Risks to fetus & mother
– Increased birth weight (C-section), low blood glucose, trauma, malformations
– Usually disappears after birth but is linked to diabetes later in life for mother
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Pregnancy Complications
Pregnancy-induced hypertension
– High-risk disorder Preeclampsia (mild form) – Eclampsia (severe form)
• Signs:
– Elevated blood pressure, protein in the urine, edema, change in blood clotting
– Convulsions in third trimester – Liver and kidney damage, leading to death
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Nutrition in Infants
Nutrition in Infancy
Water: 100-150ml/kg/day
Protein: 2-3gm/kg/day
Lipids: 3.8-6.0 gm/kg/day (MCT and EFA)
Carbohydrate:40%-50% of total calories
Calcium: 400-600mg/day
Iron: 6-10mg/day
Fluoride, vitamin D, vitamin K
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Recommendations for Infants
The WHO recommends human milk as the exclusive nutrient source for feeding full-term infants during the first 6 months after birth
Regardless of when complementary foods are introduced, breastfeeding should be continued through the first 12 months
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Breast Milk Content
Human milk contains protective antibodies against enteric infections
Caloric density is the same in breast milk and regular infant formulas(20kcal/oz)
Fat absorption is more efficient in breastfed infants when compare to infant formulas
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Breast Milk/Formula Content Human milk has higher concentration of essential fatty acid
Formula has higher protein concentration (1.5g/dl in formula vs.0.9g/dl in breast milk)
whey/casein in human milk- 80:20 whey/casein in formula-18:82
Whey protein promotes gastric emptying
Whey protein have more lactoferrin and secretory immunoglobulin A
Lactose content is equal in breast milk and infant formula
Calcium/Phosphorus ratio in human milk is higher compared to formula (2:1 vs. 1.5:1)
Human milk has lower iron concentration but iron from human milk is more bio-available
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Infection and Breast Milk
Human milk may be a source of CMV
Human milk is protective against enteropathogenic E.coli and other GI pathogens. This protection is greatest during the infant’s first 3 months of life and declines with increasing age
Human milk is not protective against HSV
Breastfeeding is contraindicated in HIV infection, except in underdeveloped countries
Human milk does not protect against M.tuberculosis
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Infant Benefits of Breastfeeding Protein in breast milk is more easily digested that protein in infant’s formula
Human milk protein promotes more rapid gastric emptying
Fat absorption from human milk is more efficient when compared to formula
Many factors in human milk may stimulate gastrointestinal growth and motility as well as enhance the maturity of the gastrointestinal track
Human milk contains specific protein involved in host defense
Infants who are breastfed for at least 13 weeks had significantly less gastrointestinal and respiratory illnesses
Breast milk appears to be protective against some food allergies during infancy and early childhood
Maternal-infant bonding is enhanced during breastfeeding
Improved long-term cognitive and motor abilities in full term infants have been directly correlated with duration of breastfeeding
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Breast Milk vs. Cow’s Milk vs. Iron-Fortified Formulas
Product Energy (Cal/oz)
Protein (g/oz)
Carbs (g/oz)
Fat (g/oz)
Cholesterol (mg/oz)
Iron (mg/oz)
Calcium (mg/oz)
Human milk
22.5 0.32 2.12. 1.35 4.00 0.01 10.0
Cow’s milk, whole
20.1 1.08 1.60 1,08 3.00 0.01 34.0
Cow’s milk, fat-free
10.8 1.08 1.56 0.03 1.00 0.01 38.0
Similac 20.0 0.41 2.10 1.08 1.00 0.36 16.0
Enfamil 20.0 0.42 2.19 1.07 0.00 .0.36 16.0
ProSobee 20 0.50 2.13 1.07 0.00 0.36 21.0
Isomil 20 0.49 2.04 1.09 0.00 0.36 21.0
Mother Benefits
Postpartum weight loss and uterine involution may be more rapid in women who breastfeed
Exclusive breastfeeding delays the resumption of normal ovarian cycles and return of fertility in most mothers
Epidemiological studies have identified a decreased incidence of premenopausal breast cancer and ovarian cancer in women who have lactated
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Infant and Nutrition
25Nutrition and Micronutrients in Pregnancy
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Dietary Fat
No fat restriction for children less than 2y
Nonfat and low-fat milk not recommended in the 1st 2 years of life
Fat intake should be decreased during toddlers years, to provide 30% of total energy
Lower limit of energy from fat should be 20%
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Baby Bottle Caries
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What not to Feed an Infant
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Dietary Guidelines in Childhood
Structured 3 meals and 2 snacks
Adults should decide when food is offered
Eating should occur in a designated area with the developmentally appropriate chair
No grazing between meals
For preschoolers offer 1 tablespoon of each food for every year of age
Snacks should be considered mini-meals
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Children: Daily food Plan
Energy/Food Groups 2-3 years 4-5 years
Calories 1000 1200
Grains 3 oz 4 oz
Vegetables 1 cup 1.5 cups
Fruits 1 cup 1 cup
Milk 2 cups 2 cups
Meat 2 oz 2 oz
Oils 3tsp 4 tsp
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School-age Children: Daily Food PlanFood Group
Age 6-7, Girls
Age 6-7, Boys
Age 8 Both
Age 9-10. Girls
Age 9-10, Boys
Age 11-12, Girls
Age 11-12, Boys
Calories
1200 1400 1400 1400 1600 1600 1800
Grains 3 oz 4 oz 4 oz 4 oz 5 oz 5 oz 6 oz
Veg 1.5 cups
1.5 cups
1.5 cups
1.5 cups
2 cups
2 cups 2.5 cups
Fruit 1 cup 1.5 cups
1.5 cups
1.5 cups
1.5 cups
1.5 cups 1.5 cups
Milk 2 cups 2 cups 2 cups 2 cups 3 cups
3 cups 3 cups
Meat 3 oz 4 oz 4 oz 4 oz 5 oz 5 oz 5 oz
Oil 4 tsp 4 tsp 4 tsp 4 tsp 5 tsp 5 tsp 5 tsp32
Adolescent Nutrition
Recommended daily allowances (RDA) for energy based on the median energy intake
Assessment of energy needs should consider appetite, growth, activity and weight gain in relation to deposition of subcutaneous fat
Restricted food intake in physically active adolescents results in diminished growth, drop in basal metabolic rate and amenorrhea
Requirements for energy, calcium, nitrogen and iron determined by increases in Lean Body Mass
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Nutritional Concerns in Adolescence The low energy intake creates difficulties in planning diets with adequate
levels of nutrients
RDA for energy do not include a safety factor for increased energy needs (illness)
Protein needs correlate more with growth pattern than with chronological age
Due to accelerated muscular and skeletal growth, calcium need is higher
Need for iron is increased to sustain the rapidly enlarging LBM and hemoglobin mass
Iron needed to offset menstrual losses
Zinc is essential for growth and sexual maturation
Growth retardation and hypogonadism have been reported in adolescent boys with Zinc deficiency
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Nutrition Concerns in Adolescents
Vegetarian adolescents at risk for deficiencies of vitamin D, B 12, riboflavin, protein, calcium, iron, zinc and trace elements
Dental caries are common (low fluoride intake, high carbohydrate intake)
NHANES reports obesity in 14% of adolescent ages 12-19
Chronic disease in adolescent may affect nutritional status
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Adolescents: Daily Food Plan
Energy/Food Group
13 yo, Girls
14-18 yo, Girls
19-20 yo, Girls
13-15 yo, Boys
16-18 yo, boys
19-20 yo boys
Calories 1600 1800 2000 2000 2400 2600
Grains 5 oz 6 oz 6 oz 6 oz 8 oz 9 oz
Veg 2 cups 2.5 cups 2.5 cups 2.5 cups 3 cups 3.5 cups
Fruits 1.5 cups
1.5 cups 2 cups 2 cups 2 cups 2 cups
Milks 3 cups 3 cups 3 cups 3 cups 3 cups 3 cups
Meat 5 oz 5 oz 5.5 oz 5.5 oz 6.5 oz 6.5 oz
Oils 5 tsp 5 tsp 6 tap 6 tap 7 tap 7 tap
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The Elderly Currently Underutilize
Resources To Combat Malnutrition
22% Use Community Services
15% Use Senior Centers
8% Eat Meals at Senior Centers
2% Receive Home Delivered Meals
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Poorly Nourished Older Adults
Greater morbidity/mortality
Declining functional status
Greater rates of hospital admission/readmission (ALOS +2days; 4x hospitalization rate)
Higher rate of complications (Tenfold increase in nosocomial infection rate)
41Nutrition and Micronutrients in Pregnancy
As we age
Body Composition
Total Body Fat
Muscle Mass
Total body water
Bone Mass (with ↑ potential of fracture)
Dentition
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Body Functions> dry mouth< taste / smell< thirst (with ↑ potential of dehydration)↑ anorexia with ↓ appetite↓ T cell and B cell activity< GFR< activity of drug
metabolizing enzymes< availability of nutrients via absorption / digestion
Food Pyramid for Older Adults
Key Considerations
More water/fluids on a daily basis Fewer calories/Encourage physical activity More fiber Consider supplements:
– calcium, vitamin D and B12
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Older Adults (70+): Daily Food Plan
Energy/Food group Females Males
Calories 1600 2000
Grains 5 oz 6 oz
Veg 2 cups 2.5 cups
Fruits 1.5 cups 2 cups
Milk 3 cups 3 cups
Meat 5 oz 5.5 oz
Oil 5 tsp 6 tsp
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Conclusions for the class
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Eating habits are learned
Eating is …..
Nutrition is ……
Exercise is ……
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